Nokea
Which type of precaution should the nurse implement to protect from being exposed to any of the hepatitis viruses?
- A. Airborne Precautions.
- B. Standard Precautions.
- C. Droplet Precautions.
- D. Exposure Precautions.
Correct Answer: B
Rationale: Standard Precautions protect against hepatitis viruses (A, B, C, D) by assuming all body fluids are infectious, covering fecal-oral and bloodborne transmission. Other precautions are inappropriate.
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Which specific data should the nurse obtain from the client who is suspected of having peptic ulcer disease?
- A. History of side effects experienced from all medications.
- B. Use of nonsteroidal anti-inflammatory drugs (NSAIDs).
- C. Any known allergies to drugs and environmental factors.
- D. Medical histories of at least three (3) generations.
Correct Answer: B
Rationale: NSAID use is a major risk factor for peptic ulcer disease, as these drugs can erode the gastric mucosa. While medication side effects and allergies are relevant, they are less specific, and family history is not a priority in this context.
The client is complaining of painful swallowing secondary to mouth ulcers. Which statement indicates the nurse's teaching is effective?
- A. I will brush my teeth with a soft-bristle toothbrush.
- B. I will rinse my mouth with Listerine mouthwash.
- C. I will swish with antifungal solution and then swallow.
- D. I will avoid spicy foods, tobacco, and alcohol.
Correct Answer: D
Rationale: Avoiding spicy foods, tobacco, and alcohol reduces irritation of mouth ulcers, indicating effective teaching. Soft brushes help, Listerine may irritate, and antifungal solutions are for candidiasis.
The nurse is assessing the client recovering from abdominal surgery who has a patient-controlled analgesia (PCA) pump. The client has shallow respirations and refuses to deep breathe. Which intervention should the nurse implement?
- A. Insist the client take deep breaths.
- B. Notify the surgeon to request a chest x-ray.
- C. Determine the last time the client used the PCA pump.
- D. Administer oxygen at 2 L/min via nasal cannula.
Correct Answer: C
Rationale: Determining PCA use assesses if overmedication is causing shallow respirations, guiding further action. Insisting on breathing, x-rays, or oxygen are secondary without cause.
The male client tells the nurse he has been experiencing 'heartburn' at night that awakens him. Which assessment question should the nurse ask?
- A. How much weight have you gained recently?
- B. What have you done to alleviate the heartburn?
- C. Do you consume many milk and dairy products?
- D. Have you been around anyone with a stomach virus?
Correct Answer: B
Rationale: Asking what the client has done to alleviate the heartburn helps the nurse understand the severity, triggers, and any self-management strategies, which are critical for assessing GERD. Weight gain, dairy consumption, or exposure to a stomach virus are less directly related to the immediate assessment of heartburn symptoms.
The client with acute diverticulitis has a nasogastric tube draining green liquid bile. Which intervention should the nurse implement?
- A. Document the findings as normal.
- B. Assess the client's bowel sounds.
- C. Determine the client's last bowel movement.
- D. Insert the NG tube at least two (2) more inches.
Correct Answer: A
Rationale: Green bile drainage from an NG tube is normal, indicating proper placement and function, so documenting this is appropriate. Further insertion or other assessments are unnecessary unless other symptoms arise.